Pediatric Council Update

By Jonathan Jantz, MD, FAAP, KAAP Pediatric Council Chair

When I worked for the Indian Health Service at Pine Ridge, South Dakota, the Ogallala Head Start program put out a bumper sticker that I had on my pick-up until I sold it years later. Those wise, but short words stated: “It is better to build children than to repair adults.” It was true then and still is true today as those children from 20 some years ago are now adults. Recent events affecting pediatricians in Kansas are quite a mix of efforts to build children and other situations where they are being ignored.

On the positive side, Medicaid announced that beginning Nov. 1, it will increase reimbursement for vaccine administration for codes, 90460 and 90461 and remove the unit limitation. At $10.50 each, it will beat BCBS for many well child visits as they are still using unit limitations.

For further comparison of Medicaid rates, I recommend that you visit the web site just released by the AAP Division of State Government at the 2010/2011 Medicaid Reimbursement Survey Report that lists 45 states (including Kansas) with the reimbursement by Medicaid for various codes.

On a parallel issue, Blue Cross Blue Shield of Kansas Medical Director Mike Atwood has responded to the letters chapter members sent regarding the reimbursement for the vaccine administration and handling codes of 90460 and 90461. Many of you may have received his response. We are planning on meeting with him again concerning this important issue. In the month prior, they had increased the rates slightly, but decreased the unit limitation so that payment for storage, handling and administration of vaccines was essentially unchanged. Kansas Academy of Family Practice board is also considering how to respond to the issue at this time.

Blue Cross Blue Shield has announced some changes in reimbursement for 2012, and some they have not announced, but it seems likely they will institute them. They have to do with EVERY use of modifier 25.

From the Blue Shield Report S-90-11, they are announcing a “Modifier 25 Clarification-2012 Contract Change.”

As outlined in the 2012 CAP contract letter, effective with claims for service dates on or after January 1, 2012, BCBSKS is changing the reimbursement administration when using modifier 25 to bill and additional service. Reimbursement will be allowed at 50 percent of the maximum allowable payment (MAP) on the service billed with modifier 25. This is not a departure from CPT coding guidelines, but change in reimbursement for identified services.

• Do use modifier 25 on E&M codes that are separately identifiable and done in conjunction with another service that is subject to the global fee concept.

• Do use modifier 25 on E&M codes only.

• Don’t use modifier 25 when billing new patient E&M codes.

• Don’t use modifier 25 when billing an E&M code with a code that is not subject to the global fee concept. (Refer to the Blank Classification Listing on the BCBSKS Web site.)

• Don’t use modifier 25 when it is the only service on the claim.

• Don’t use modifier 25 when billing an E&M along with a service that BCBSKS policy memos do not allow on the same date of service, i.e., therapeutic injection administration, more than one E&M on same date of service, etc.

The trick here is to maximize reimbursement under BCBS in a way that can be justified to them, while still being consistent for the other insurances.

Each office will have to decide what course of action to take with regard to the following issues:

1. Discharge same day as circumcision or clip of tongue tie – Currently, we are paid for a circumcision or frenulomectomy and a discharge done on the same day with a 25 modifier. However, beginning Jan 1, BCBS will not pay for both as separate items, bundling them, which will cut the discharge in half.

We can’t do it as a subsequent hospital visit, because they will cut the subsequent hospital visit in half and there is no option to increase that by time. Every male child discharge will have this.

One option to deal with this is that if you do a circumcision tongue tie clip on the day of discharge, use a 99293 for the discharge which is for greater than 30 minutes. The increased time required to achieve the 99293 code should be easily covered by the increased counseling for the procedure and discussion of care afterwards. This should make up some of the difference, although we don’t know for sure exactly how much that will be.

2. Discharge same day as tongue tie with circumcision– If we do a tongue clip, circumcision, and discharge in the same day, the tongue clip fee (the least amount) will be cut in half AND the discharge fee will be cut in half.

Again, the solution is to use 99293, for the same reasons as above.

3. Office visit same day as allergy shot – Currently, BCBS pays $42 for an OV, $13 for allergy injection. If done on the same day, will be half OV ($21) and $13 for allergy injection.

Reasonable medical issues: Should they be getting an allergy shot if not well? What if there is a reaction? Is there a higher chance of reaction if they are sick (may depend on the type of sick)? Would the reaction be worse if they are sick?

4. Warts – As always, warts on the same day as an OV cuts the OV in half.

If patients complain the unfortunate solution is just to blame the insurance company. The basic point is that by providing patients with the convenience of treating medical problems on the same day as a procedure, the insurance company penalizes the physician.

This Just In
Merck recently announced that it will be increasing prices 4% on VARIVAX, MMR and Rotateq vaccines. You may want to contact your representative for details about when it will affect your purchasing. Then I would recommend contacting insurance companies that you contract with to make sure they will increase reimbursement appropriately.